When you are on a stretcher in an emergency room complaining of abdominal pain and fever for 2 days, do you have a preference whether the physician who introduces himself as your health-care provider is a male or female? The medical encounter is a central part of health-care delivery, and it influences the experience of the health-care receiver as well as probably influencing short-, medium-, and long-term outcomes [Figure 1] adapted from Bertakis.[1] The interaction of physicians and patients during these clinical encounters is complex[2],[3] and the sex of either the patient or health-care provider and its influence on that encounter and the subsequent outcomes have been a material of numerous studies.[4],[5],[6] Important to note, perceptions of individuals receiving health care could be influenced by stereotypes,[7] role expectations, as well as previous experiences.[1] In this issue of the Journal of Nature and Science of Medicine, Alyahya et al. conducted a community survey attempting to look at the preference of participants when it comes at choosing their health-care provider based on sex. Is there a difference between male and female physicians?

Figure 1: The patient-physician interaction and expected outcomes that was adapted from Bertakis[7]

In a large survey of physicians from the USA using a revised version of the Jefferson Scale of Physician Empathy; female physicians had a higher mean score in empathy compared to males. Furthermore, empathy was found to be variable even between specialties, which again could add to the complexity of the interaction.[8] In a randomized controlled trial where patients were assigned to either internal medicine or family medicine clinics and followed up for a year; female physicians offered more preventive services and psychosocial counseling while male physicians spent more time on technical practice behaviors (e.g., history taking and physical examination).[1] Furthermore, patients of female physicians were more satisfied.[1] Differences in satisfaction of the patient-physician encounter have also been demonstrated in Japan with a higher satisfaction with female health-care providers.[9] Other areas that might affect the choice of the health-care provider might be related to the expected length of the therapeutic relationship.[1]

This study at hand demonstrated that for the majority of cases there was no preferences by the participants when it comes to the sex of the health-care provider except in a few situations that somewhat appear intuitive. Although the paper is an important addition to the literature that is needed regionally and would help understand the population's preferences, it does not dwell into the underlying source of this apparent choice. It would have been of benefit to use a tool to assess the derivers of choice in the participants rather than a simple question that directly asks the participant's whether their choice was influenced by sociocultural factors.

The statistical differences in the comparisons made in this paper are a function of the sample size; a more appropriate reporting of 95% confidence intervals might have been a better measure to assess the magnitude of differences in responses. We believe that the responses preferences of participants of the study are influenced by the age, cultural background, values, and other factors. As such a multivariable analysis where these factors are taken into account when modeling would have been insightful in teasing out what really drives these choices to better understand the values of the public and build on these in the education of undergraduate and postgraduate programs.

Furthermore, it should be kept in mind that the study by Alyahya et al. was conducted in a single city, Riyadh, and might not be representative of the Kingdom as a whole and thus would caution against the statement of it being a national study. Furthermore, we would be a bit conservative when it comes to the explanation that the findings might be related to the inclusion of “young generation who could be less restricted by sociocultural factors” as the data acquired do not permit such a conclusion. Likewise, their conclusion that “there is no effect of sociocultural norms on patients' choices for the gender of their treating physicians” is not supported by their data. In addition, the statement that the study could be used in “physicians' placement in different clinical services” is a leap of faith in the results of a single study that has several significant limitations.

Choice and decision-making is a complex process that is subject to major conscious and subconscious influences, and that has been of great interest for centuries for scientists across many disciplines including psychology, economics, mathematics, and political sciences. These studies purposed a number of theories that explain human behavior in choice and decision-making. The most prominent of which are: Solomon Asch' Social Conformity Theory, Choice Theory by Glasser, Nudge Theory by Thaler and Sunstein, and Marginal Utility Theory. Conducting and interpreting studies on individuals' choices, preferences, and decision-making have to be done in the context of these theories to avoid serious flaws that potentially threaten the validity of their results. Delving deeply into these theories is beyond the scope of this editorial. Interested readers can refer to appropriate references that provide more details about this subject.

Equally important, the questionnaire-based surveys are also subject to many biases; most consequential are framing and anchoring biases. The questions' wording and order (framing) can have a significant influence on individuals' responses.[10] Similarly, anchoring which is the cognitive bias that results from thefirst piece of information one receives had been shown to affect subsequent responses and choices.[11]

So coming back to our question in the beginning, do people have preferences to the sex of their healthcare provider in the emergency room? For the greater part not, but for a significant proportion it does and we still need to know why.